ANA Discussion Forum

Pre-Treatment Options => Pre-Treatment Options => Topic started by: ASG on July 26, 2013, 11:03:07 am

Title: What constitutes "high volume" surgical experience?
Post by: ASG on July 26, 2013, 11:03:07 am
I was diagnosed with a 3cm AN (left side) in June, and have been researching treatment options ever since (including spending a lot of time on this website).  I'm 31 years old, and currently have 5% tonal hearing loss (high frequency), and perfect speech discrimination in the affected ear.  I have tinnitus, minimal balance problems, and minimal facial numbness as well.  Like many, I've sought multiple consultations: Dr. Slattery at the House Clinic, Dr. Chang at Stanford, and Dr. Thompson at the University of Michigan (with UPMC and MEI coming up).  Right now, if I were to go with microsurgery, it would be between Dr. Slattery and Dr. Thompson. It's important that I work with a surgeon who completes a "high volume" of AN procedures per year.  My first question is, how many AN surgeries does one need to complete a year to be considered "high volume"?

Dr. Slattery completes 300 AN surgeries per year, including 150 translab procedures (his recommendation for me).  He has been doing these surgeries for about 20 years.

Dr. Thompson completes hundreds of skull base surgeries per year, including 40-50 two stage sub-occipital/translab procedures for AN (his recommendation for me).  He also has been doing AN surgeries for about 20 years and has completed over 900 AN surgeries in his career.  Another fun tidbit: according to Dr. Thompson, House Clinic has twice tried to hire him.

Are both these surgeons high volume, or just Dr. Slattery?  Is Dr. Slattery significantly more qualified than Dr. Thompson, or at some point is there some law of diminishing returns with AN surgical experience and they are about the same?  U of M is 5 minutes from my house and in my insurance network.  Is it worth it to fly to LA when I have Dr. Thompson in my backyard?

You can also see that each surgeon recommended a slightly different approach!  Dr. Thompson said that recent findings have shown that a two stage approach (sub-occipital first, translab second) has a better likelihood of facial nerve preservation because you can see the nerve from two different angles.  When I told this to Dr. Slattery he said he, "didn't understand" this strategy because the entire tumor could be removed with translab and a sub-occipital approach could damage the cerebellum.  I then conveyed this back to Dr. Thompson, who said that there was no way "in modern surgery" one could damage the cerebellum with a sub-occipital approach, that it has not only never happened in his career, but never happened in the history of the neurosurgery department at U of M. 

He went on to say that House Clinic is a great place with great surgeons and I would be in good hands if I chose to go there.  However, he knows the surgeons personally and knows that they usually do just middle fossa or translab, and not the two stage at this time (which he says is best).  He noted that U of M has the best hearing preservation outcomes for middle fossa (84%) with House Clinic Second (68%).  I can verify that the U of M outcome data were published in the journal "Neurosurgery".  Even though I'm not a candidate for middle fossa, the idea is that a surgical team can't be excellent at one approach and not the others.  Thus in this case, does sheer volume of cases necessarily trump everything else when it comes to treatment recommendations?

Both Dr. Slattery and Dr. Thompson were incredibly nice.  Both gave the "if it were my brother I would do X" statement regarding their recommendation.  Its a very hard choice because I am not sure how to compare their level of experience and expertise.

What a long post!  Sorry about that.  I also have questions about radiation (what Dr. Chang recommended), but I will post those questions next week after I speak with UPMC.  Thanks in advance for reading and providing any thoughts or feedback!

Title: Re: What constitutes "high volume" surgical experience?
Post by: LakeErie on July 26, 2013, 04:35:58 pm
Both surgeons are eminently qualified in terms of experience. You just need to decide which surgeon's methods appeal to you if microsurgery is your choice versus radiation. When considering radiation, both Stanford and UPMC are high volume AN treatment centers. 
Title: Re: What constitutes "high volume" surgical experience?
Post by: Cheryl R on July 26, 2013, 05:33:28 pm
I have a feeling there could be a variable in answers to your question as no 2 people think alike.          I am in Iowa and go to Univ of Iowa where Dr Gantz does 70 plus a year and for many years as I have been his patient since 2001 due to NF2.             To me this is enough experience.          They do other skull base surgeries also.       I would not go to a dr who did 4 or 5 a year.                 There would be a protocol on how each type is normally done.        Also some places do not do mid fossa or rarely retrosigmoid.      Iowa City does more mid fossa than Mayo's.                 There is never a guarantee with AN surgery due what may be found once they are inside.        House has had their share of those who end up with problems too.       I have met Dr Slattery and know he is very good as I have been to 5 AN symposiums and he does the NF2 sessions.           I would be concerned over the 2 step way Dr Thompson does as see no reason for it to not be done in a one surgery removal.     You do have too large of a tumor for mid fossa.         I would maybe see another surgeon if do want a one surgery removal.        Making the right decision that you are comfortable with is very important.           This is not an easy choice and let us know how it goes.                            Cheryl R           
Title: Re: What constitutes "high volume" surgical experience?
Post by: Pam Fraley on July 26, 2013, 07:19:25 pm

I am currently a patient of Dr. Arts at U of M (wait and watch) and if I have surgery, Dr. Thompson will be my surgeon.  I have talked to a few people who have had Dr. Thompson for their surgery and have had very good outcomes.  If you would like, I can send you a personal message with their contact info.  They also did lots of research before deciding on Dr. Thompson.

Good Luck,

Title: Re: What constitutes "high volume" surgical experience?
Post by: RachelSta on July 27, 2013, 06:45:49 am
I had translab surgery at U of M on 5/29. Dr. El Kashlan was the neurotologist and Dr. Thompson was the neurosurgeon. I felt I received wonderful care and had a great outcome. I think you probably can't go wrong with either surgeon with whom you've consulted. I also considered going to House, but ultimately decided I didn't want to travel for surgery. Both U of M and House have great outcomes and both have patients who come out with some kind of complication.

Ultimately, you need to feel comfortable with the surgeon you choose. I didn't want to travel and I wanted local doctors should I need some kind of follow up treatment. Like you, I felt A LOT of stress as I was trying to make a decision. Once I made my decision, I felt much better. Don't get me wrong - I was still nervous about having someone drill a hole in my head, but I felt good about where I was having surgery.

Feel free to message me if you have any questions about my experience.
Title: Re: What constitutes "high volume" surgical experience?
Post by: ASG on July 27, 2013, 07:51:21 pm
Thanks so much everyone for the feedback!   I think with all my research I may have been getting inside my head too much, and worrying that anything other than going to House would be compromising my health.  These thoughts are very reassuring and put things in perspective.  I still have a lot of thinking to do, but its nice to be reminded that going with your gut is important.

I forgot to mention, Dr. Thompson also explained that the two stage approach allows the surgeon to stop the procedure and pick up later if things are dragging on.  For example lets say its getting to the 11 hour mark of the surgery, at midnight, right before getting to the most critical stage of the surgery (the facial nerve), and the surgeon is exhausted.  With the two stage approach, the surgeon can stop, and complete the surgery another day when they are feeling fresher (this would be the translab part).  Or they could just knock it out in one session if they felt good.  I guess the two stage approach gives them some flexibility.

Pam and Rachel, I really appreciate hearing your experiences at U of M.  I have El Kashlan as my ENT.  I will definitely message you to hear more.
Title: Re: What constitutes "high volume" surgical experience?
Post by: nftwoed on July 28, 2013, 06:12:49 pm
Hi Cheryl;
   I wonder if Dr. Gantz still has Residents or colleages perform his part of the surgery and they are credited with the surgery. I believe he supervises.
   By comparison, 70 sounds like very few to 200 for Dr. Slattery. Gantz is one of the best!
   I had a young, Dr. Harker, supervised by Dr. Gantz, perform my Translab.
   Like you, I'm not very excited about a two stage surgery. Between the Neurotologist ( licensed for neurosurgery ) and Neurosurgeon, they should be able to finish this in one op.
Title: Re: What constitutes "high volume" surgical experience?
Post by: nftwoed on July 29, 2013, 07:32:19 am
Hi again, Cheryl;
   Seems I recall a Dr. Rosenthal working either as a Resident, or colleage of Dr. Gantz's? I'm unsure if he's still at UIHC.
Title: Re: What constitutes "high volume" surgical experience?
Post by: Cheryl R on July 29, 2013, 05:04:02 pm
Hello and no Dr Rosenthal that I ever heard of since my years going to UIHC.         But it's been since 2001 and maybe wasn't paying a lot of attention at first.    Sure didn't know this was going to be an ongoing happening.         Cheryl R
Title: Re: What constitutes "high volume" surgical experience?
Post by: Cheryl R on July 29, 2013, 05:09:41 pm
At UIHC the current Fellow does the open and shut part of the surgery and Gantz does the tumor.     I know residents observe and never asked what they may have some part in.      I've seen enough residents now too.                 Harker must have been the Fellow at the time of your surgery.           
                                      Cheryl R
Title: Re: What constitutes "high volume" surgical experience?
Post by: nftwoed on July 29, 2013, 08:56:15 pm
Hi Cheryl;

   You wrote: "I've seen enough residents now too". This brings a smile to my face as I recall UIHC so. It seems every visit, a Resident performed a Dix-Hallpike maneuver on me and checked for nystagmus and essentially said nothing to the Dept. Head except, "Yes, Masta". : )